GW1-2023-01209_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Cori tractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name FROM TO DFSCRtP1'ION
3441A / 6 rr. J�5 rr. f0' �'►1
NC Wcll Contractor Certification Number ft. ft.
NW Poole Well and Pump Company 15.OUTER CASING for multi-cased wells OR LINER ifit nanblc
FROM TO DIAn1E'rEIt I THICKNESS I MATERIAL
CompanyNama '+.I ft. l� 5 fr' .� in. • 1�� �tsrcJ/-•�✓
> - /� G II.INNER CASING OR TUNING cothermat cto3ed-lao n 2.Well Construction Permit#: (T w- t/S I Oa -ZoZ FROM TO DIAIIIETER THICKNESS MATERIAL
List all applicable well constnictlon pernats('.e.UIC,County,State,Variance,eta) ft. ft. irr
3.Well Use(check well use): ft. ft.
=(licajing/Cooling
Well: 17:SCREEN
FROM TO DIAh1ETER SLOTSILE THHCKNFSS h1ATER1,1L
❑Municipal/Public tL
Healing/Cooling Supply) [tesidential Water Supply(single)lnmcrcial ft.❑Residential Water Supply(shared)
18.GROUT
❑Wells>100,000 GPD rnoM TO MATERIAL EhIPLACE51ENT nIEr1i0D S ANIOUNT
Nan-WatcrSupply Well: � ft.
❑Monitoring ❑Recovery It. � t 4 C.)!
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation tr rt.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/G RAVEL PACK ifa licable
❑Aquifer Test Boni TO 51ATEIUAL EMPLACEMENTMETHOD
❑Storinivater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
fr. ft.
❑Geothennal(Closed Loop) ❑Tracer
10.DRILLING LOG attach additional sheets if necasa
❑Geothermal(Heatiiig/Cooling Return) ❑Other(explain under#21 Remarks) FRO To DESCRUPI'lON coin,;knriness,soil/rocktrre, ruin size,etc.
4.Date Well(s)Completed: -Z/-z Wcll ID# Oft. � -� 50"e -
a ft.20
Sri.Well Location:
_!Q)-5 ri GrAn•kchuyy ' Cil:' ft. ft.
facility/OwncrNarnc Faeiliry ID8(ifapplicable) ft. ft.
71170 80rX •�ocLd In)�rti�c-l( /!/G� �'?S?/ ft. a.
� 20
Physical lAddress,City,and Zip
21.REMARKS In ••Cii?r^.:O1a�ri.:v^� r,'.�� �13.
County Parcel Identification No.(PiN) Used hardened steel drive shoe.
56.Latitude and longitude in degrees/nunutcs/seconds or decimal degrees:
(ifwcll field,one IaVlong is sufficicri()
C• �0 1 22.Ccrtifican
J "1�52 N -- �1S' 1,:3'olill�oV W
( Z-2-1- 2 2
6.Is(arc)fire well(s): ❑Permanent or ❑'I'ernPOrary' Stgnaturo ofCcrt;ficd Wcll Contractor Uy sig �-
Date
ning dNs jornt,ihereby certify'1101 film 1-11(.r)erns(here)constructed in accordance with
7.Is this a repair to an existing is-ell: ❑yes m' bNo 15ANC4C 01C.0100 or 15A NCAC 01C.0100 Well Construction Slardaruls antI I a co/n
/Jr/ri.r ,fr/l out known well eonstniction it jonnalloq,and explalrt the nature ojNie oJdBs record has becutprnrfded In the rue/f ou nm.
Is o repair
repair raider N,21 remarks sectlon at,oil due back of ads fount: ''
`.;u:irr;l''• 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die Sarno You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBL-R of wells (add'Sce Over'in Remarks Box).You may also attach additional pages ifnecessery.
drilled:t I,'. ui: l
I I:Zr s 24.SUBMITTAL INSTRUCTIONS
9.Tota1'yell depth below land surface: (ft)rnrnadtiple u•ells list all depihs fdi(/creni(esamp/c-3@200'and2©100') Submit this GW-1 within 30 days ofwell completion per the following:
10.Stade water level below top of casing: 2� 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijirarer level is above caring;use"t•' (f t) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole dinmetci. 6 '(in.) 24b.For Infection Wells: Copy to DWR, Underground Injection Control(IUC)
Rota Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
(i.e.auger,rotaty,cnblc,direct push,etc.) 24e.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY.W ELLS ONLY:
24d.For Water Wells producing over 100 000 GI'I)•Copy to DWR,CCPCUA
13a.Yield(gpnn) Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:'1 lb.
I
Fomr G1V-1 North Carolina.Department orlinvironmental Quality-Division of Water Resources
a,.,,i-d r..4_7n rr